Q. When I compare health insurance plans in the exchange for our family, they all show total family deductibles and out-of-pocket maximums (OOPMs). Does that mean we’d have to meet the full family out-of-pocket limit, even for just one person?
A. As of 2016, no (and even before that, the answer was usually no).
Prior to 2016, family plans could have aggregate deductibles and OOPMs, or they could have embedded individual deductibles and OOPMs. With an aggregate deductible, you have to meet the full family deductible before any of your after-deductible benefits kick in, even if it’s just one family member with claims. And the OOPM is one total for the whole family, even if just one family member has claims.
But with embedded deductibles, there are individual deductibles built into the family deductible, and each family member is only required to meet the individual deductible before after-deductible benefits kick in for that family member. Once the amounts paid towards individual deductibles meets the total family deductible for the year, everyone in the family is eligible for after-deductible benefits for the rest of the year (on plans like this, the OOPM is also embedded for each person on the plan).
Most health insurance plans already used embedded deductibles and OOPMs. But if you want to contribute to a health savings account (HSA), you need to have an HSA-qualified high deductible health plan (HDHP). And prior to 2016, most HDHPs had aggregate deductibles.
But this was changed with the 2016 Notice of Benefit and Payment Parameters. That regulation clarified that starting in 2016 (for plans that are not grandfathered or grandmothered), no individual can be required to pay more that the individual out-of-pocket maximum, even if the individual is enrolled in a family health insurance plan.
For 2016, the individual OOPM is $6,850, and the family OOPM is $13,700 (these are increasing to $7,150 and $14,300 in 2017, although many health plans will continue to have OOPMs lower than these amounts). Under the new rules, no single member of a family can be required to pay more than $6,850 in out-of-pocket charges in 2016, regardless of whether the rest of the family has incurred any claims. This includes people enrolled in family HDHPs, and HHS has clarified that this does not conflict with HSA and HDHP requirements.
If you’re browsing plans in the exchange, in many states they only show family deductibles and OOPMs on the multi-plan comparison screen if you enter information for more than one family member. So you may need to look a little further to see what the individual OOPM is. In 2016, it won’t exceed $6,850, and in 2017, it won’t exceed $7,150.
But as long as you have an ACA-compliant health plan, you can rest assured that if a only one member of your family needs extensive medical care during the year, your out-of-pocket costs will be capped at no more than $6,850 in 2016, even if your plan has a family OOPM of $13,700.